Provider Demographics
NPI:1518418680
Name:DENTAL PROFESSIONALS OF INDIANA, PC
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF INDIANA, PC
Other - Org Name:REGAL VALLEY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-821-7249
Mailing Address - Street 1:2000 VETERANS MEMORIAL PARKWAY S
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909
Mailing Address - Country:US
Mailing Address - Phone:765-746-6166
Mailing Address - Fax:765-746-6935
Practice Address - Street 1:2000 VETERANS MEMORIAL PARKWAY S
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909
Practice Address - Country:US
Practice Address - Phone:765-746-6166
Practice Address - Fax:765-746-6935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF INDIANA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-24
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty